Nursing: Psychiatric-Mental Health, Gerontological/Geriatric, and Geropsychiatric

Description of Specialty

Nurses at various levels of education are prepared to address behavioral health problems. Two levels of nursing practice are widely recognized.

Advanced practice nurses (APNs) are master’s or doctorally prepared nurses who have concentrated skills in a specialized area of practice, such as psychiatric-mental health (PMH) or gero/geriatric nursing. These nurses are called a variety of names, including advanced practice nurses, advanced registered nurse practitioners, clinical nurse specialists, or nurse practitioners. Their scope of practice varies based on their educational preparation, clinical interests and training, professional certification, and licensure in individual states. Geropsychiatric APNs consist of PMH advanced practice nurses who have specialized skills in geriatric care, AND gero/geriatric APNS who have specialized skills in psychiatric care issues.

General practice nurses (GPNs) are licensed as registered nurses (RNs) and have developed specialized skills through clinical experience, continuing education, and self-directed learning activities. Both PMH and gero/geriatric generalist specializations are relevant to behavioral health concerns of persons with dementia. Gero-geriatric nurses who have worked in long-term care (LTC) settings as nurse leaders (e.g., former directors of nursing) are often well-prepared to serve as consultants due to their specialized knowledge of behavior management in the context of LTC policies. PMH generalist nurses may also provide assistance in managing behavioral disturbances based on their expertise in acute and/or community psychiatric nursing.

Educational Requirements

Advanced practice nurses are licensed registered nurses (RNs) who have master’s or doctoral degrees. A variety of educational degrees lead to being an APN, including master of arts (MA), science, (MS) or master of science in nursing (MSN). Doctoral education may include doctor of philosophy (PhD), and doctor of nursing practice (DNP), and [list others]. General practice nurses are also licensed RNs who have an associate degree in nursing (ADN), diploma in nursing, or bachelor of science in nursing (BSN) degree.

Licensing Requirements

Nurses are licensed by the state in which they live. Both advanced and general practice nurses have registered nurse (RN) licensure. Advance practice nurse licensure varies by state based on the scope of Nurse Practice Acts in the state. For example, in Iowa, APNs who are certified by their professional credentialing organization are eligible for licensure as an advanced registered nurse practitioner, or ARNP. For assistance in identifying variations in your state, contact the state board of nursing.

Specialty Credentials Related to Geriatrics

The American Nurses Credentialing Center (ANCC), which is part of the American Nurses Association (ANA), is a widely used credentialing agency for nurses. Nurses who meet specific criteria for education and clinical experience may be certified by ANCC as an PMH nurse practitioner or clinical specialist (CNS), OR as a gerontological NP or CNS. There is currently no certification for geropsychiatric NP or CNS specializations.

Scope of Services in Long Term Care Settings

Variability in education, clinical training and practice experiences are critically important when evaluating the potential helpfulness of either an APN or GPN consultant. Both APNs and GPNs may have skills in system integration, education, behavioral health assessment, decision-making, and use of non-pharmacological approaches for persons with dementia based on their education, interests, and clinical experiences.

Individual interests, clinical skills, and preparation are critical to consider related to sub-specialization within the individual APN’s practice. For example, PMH specialization may focus on child, adult, or gerontological problems. Gerontological nursing specialization may focus on psychiatric/behavioral problems or other medical conditions such as diabetes or heart failure. Thus, advanced practice PMH nurses may be prepared to facilitate system-related problem-solving, educate staff and family, and assess and treat medical, psychiatric, and social problems that cause or contribute to behavioral health in older adults. Similarly, GPNs may also have advanced skills in these areas based on their experiences and educational preparation.

  1. System Integration: Both APNs and GPNs may have skills to facilitate the adoption of evidence-based practices and facilitate system-related changes to promote the identification and resolution of communication, care coordination, assessment, and treatment issues related to behavioral health problems/issues. The APRN plays a significant role in the assessment of and providing recommendations for changes in the environment using tailored interventions. The needs assessment requires continuous follow up due to staff turn over. Resident-family education is also ideally provided on an ongoing, tailored basis. Policy development for the facility is rooted in effective communication and accurate description of resident behaviors. To successfully sustain improvement, the assessment process is ongoing, deliberate and must be implemented collectively and individually.

  2. Education: Both APNs and GPNs may be excellent resources for educational/staff development activities. This includes both formal and informal (just-in-time) teaching with nurses and nursing assistants and other personnel (e.g., activity, dietary, housekeeping, maintenance, administrative; occupational, physical, speech therapies). There are a variety of teaching methods including webinars, power point presentations, videos, and pocket cards. The APRN must know and evaluate the online resources and provide an awareness and appropriate direction for educational strategies.

  3. Leadership: Both APNs and GPNs may act as change agents and leaders and gain skills through involvement in professional organizations.

  4. Assessment: Both APNs and GPNs may have skills to conduct/facilitate behavioral health assessments, clinical decision-making, and use of non-pharmacological approaches for persons with dementia based on their education, interests, and clinical experiences. In general, APN psych and gero specialists are educated to provide assessments related to symptom frequency, severity and duration and trained to use the recommended screenings in the tool kit. An important barrier is follow up by the facility, as time constraints are a factor. Also, the MDS is widely used, but often not accessed by providers. Often screening tools are administered by social workers in the nursing home. Therefore, APRNs must use an interprofessional approach in behavior management and consult with other disciplines such as PT, OT, and social work. Additionally, the timing of the assessment should coincide with the time of day behavior management is most needed. For example, if daytime sleepiness is a suspected factor for nighttime behaviors, assessment with recommendations for increased daytime activity should be done in the daytime. All nurses notes and narrative nursing documentation should be read as part of the assessment and development of a behavioral health plan. This is especially important in the assessment of persons with more severe dementia.

  5. Clinical Decision Making: As noted above, the skills of the ANP or GNP are individually defined based on their education, clinical training, and interests/experiences in LTC behavioral health management. In general, ANPs are educated to provide assistance with clinical decision-making, including direct and indirect (consultation-based) management of medication regimens and behavioral care plans. GPN skills are similarly determined by their clinical history and experiences in behavioral care planning and management. The recommended models on the website are excellent, however, often the process is only partially carried out. APRNs must be allowed time to collect information that may be missing in the decision making process.

  6. Non-pharmacological approaches: As above (D and E). Additionally, the APRN must be willing to demonstrate non-pharmacological interventions, such as how to calm agitation, for example, by removing a resident to a less stimulating environment, holding a hand, and/or playing music. In general, knowing the resident and taking the time that is necessary for behavior management is key to the success of the intervention. The role of the APRN is to educate and empower the nursing staff to use non-pharmacological interventions.

Resources for Finding this Specialty in Your Area

Professional Organizations

As above, plus Gerontological Advanced Practice Nurses Association, Hartford Gerontological Nursing Leaders, Geropsychiatric Nursing Focus Group

Optional items

Third Party Reimbursement Eligibility

Recommendations for behavioral management are included, as a part of the office/facility visit. For primary care including FNP, GNP, AGPCNP there are no separate charges. PMHNP are trained in cognitive behavioral therapy. However, this can be a “red flag” in persons with dementia who are so cognitively impaired that there is little-no benefit for cognitive behavioral therapy. The APRN may recommend changes in environment and approach.

Acknowledgement: Thank you to Marianne Smith, PhD, RN and Melodee Harris, PhD, APRN, GNP-BC, FNGNP for their review of and contributions to the content.